"Finally, what about the issue of neoplasia and cancer? It is thought that immunomodulating drugs can, in general, predispose patients (humans and dogs) to some forms of cancer, thus the FDA has certain labeling requirements concerning immunomodulating drugs. The Apoquel package insert carries a warning that Apoquel “may exacerbate neoplastic conditions.” There is no way to disprove this statement, so although no neoplasms were observed in the laboratory safety studies, and the causality of some of the tumors that developed in the field trials were ruled out based on a very short period of time between starting the drug and tumor diagnosis, the statement sticks. Here is the information available regarding the open-label, long-term continuation study (239 dogs) in the Freedom of Information Summary:

“Six dogs were euthanized because of suspected malignant neoplasms: including one dog each with thoracic metastatic, abdominal metastatic, splenic, frontal sinus, and intracranial neoplasms, and transitional cell carcinoma after 17, 120, 175, 49, 141, and 286 days of oclacitinib maleate administration, respectively. Two dogs each developed a Grade II mast cell tumor after 52 and 91 days of oclacitinib maleate administration, respectively. One dog developed low grade B-cell lymphoma after 392 days of oclacitinib maleate administration. Two dogs each developed an apocrine gland adenocarcinoma (one dermal, one anal sac) after approximately 210 and 320 days of oclacitinib maleate administration, respectively. One dog developed a low grade oral spindle cell sarcoma after 320 days of oclacitinib maleate administration.”

Ideally we would evaluate the prevalence of each diagnosis against a database of dogs with a comparator group with similar demographics. But of course that isn’t readily available. So we are left to consider whether the prevalence of neoplasia in these 239 dogs (5%) is unusually high. My local veterinary oncologist and I don’t find the prevalence unusual, although we don’t have all the demographic data that would help us evaluate it."

I know the evidence is sketchy but cancer is a hot button issue for me; as my 2 major losses (one person, one dog) were both due to cancer and just the mention of the "C word" freaks me out.

Anyone have any thoughts on this? I really think I'm going to hold off if I can get by with mostly zyrtec and the occasional temeril p for flare ups. I know neither of those are great options...but I'm not aware of a cancer connection...

I would feel better if Apoquel had been on the market A LOT longer with more longitudinal studies....

Apoquel would potentially replace long term prednisone or cyclosporine in treating refractory allergies, both of which are immunosuppressive and therefore can cause/exacerbate cancer. Now which is the "worst" - I don't think we have enough data to say that yet. Theoretically Apoquel is the most specific for allergic inflammation versus the rest of the immune system so theoretically has less side effects on the rest of the body but I don't think we can know if that theory is actually true yet since it's so new.

I think any of the three drugs, used long term, are a last resort and that management with hyposensitization, diet adjustment, fish oil, vit E, topicals, and antihistamines should always be a preferable long term plan over immunosuppression. Non-immunosuppressive treatment doesn't work completely for all animals but should definitely be explored to hopefully get off the immunosuppressives or at least reduce the dose. My dog was able to have his Temaril-P (which includes prednisone) reduced down to every 3 days instead of every day by using supplements, topicals, and antihistamines.

PITtsburgher wrote: diet adjustment, fish oil, vit E, topicals, and antihistamines should always be a preferable long term plan over immunosuppression.

Ditto.

I also want to add that lowering your dog's skin temperature through exercising it in "cold" water can also do wonders for immunity, hormonal balance, and inflammation. If I were a vet, I'd add on a +3x week +20 mins of swimming in cold water as a necessary part of treatment, specifically to reduce the amount of antihistamines needed.

If your dog (or you) are extremely sensitive to the cold, this can indicate an issue with fatty acid ratios in the cellular wall structure leading to hormonal issues. The hormone receptors are the wrong shape, so hormonal communication doesn't work effectively or efficiently. Swimming at temps more than 20 degrees less than skin temp spurs the body to recycle these molecules into more appropriate ratios. (This is one of the reasons cold climate cultures do ice baths in the Winters to spur immunity.)

And for those who think I haven't tested this theory myself Kobe Bryant sits in an ice bath for hormonal reasons that speed recovery and boost testosterone naturally.

Misskiwi67 wrote:I agree with the cold water being good for skin, and cool water rinses are on the label instructions for every medicated shampoo I prescribe.

I'm recommending it because it is good for the brain. Skin condition is an excellent indicator for locating issues in both the GI and Brain chemistry. (For instance, those of you with acne issues... look at your face. If the acne is located above your cheekbones, it is a GI issue and you need to stop washing your (organic) veggies, start taking a broad-spectrum probiotic, and learn to make home made fermented veggies. Those with acne below the cheekbones, this is a Brain (hormone) issue... no more dairy for you! Ever wonder why Dermotologists prescribe the Pill? Yup, this is why. But don't go on the Pill to fix your skin, it messes up too many other things later on down the road.)

This is especially important if your dog is carrying excess weight. This indicates a hormone, Leptin, is not working properly. (Leptin is VERY important: http://en.wikipedia.org/wiki/Leptin#Inflammatory_marker) Exposure to cold helps the body restore leptin sensitivity, restoring hormonal function, which then aids immunity, reducing inflammation, and finally, improving the skin.

The skin is the last place you see the damage and the last place you'll see the results. This is why when you see skin issues, you know the other systems are trashed. (The body is an amazingly beautiful machine that has many mechanisms to try to prevent chemical weaknesses that cause disease.)

Leptin is also the reason why you should not feed a dog with GI/skin allergy issues more than once a day (preferably low carb/high fat) and weekly 24-hour fasts will also speed recovery due to reducing inflammation.

The issue with using cold is that it requires 20 minutes, minimum, of temps preferably around 55 degrees to have any lasting hormonal benefit as the "cold" signal has to reach the brain (http://en.wikipedia.org/wiki/Hypothalamic%E2%80%93pituitary%E2%80%93adrenal_axis). If you have access to warmer bodies of water, you can get similar results, but it takes longer. 45 mins in a 50-55 degree body of water 3x a week will do wonders.

(Oh and yes that testosterone boost will help mood/optimism, muscle tone, and muscle mass. )

According to V.'s dermatologist there is a nationwide shortage on apoquel and she doesn't expect to get it until 2015. She said might get it (being a specialist) fall 2014.

Missk - could you elaborate on your comment below. Are apoquel and cyclosporin in the same family? What would you consider to be "the safer alternative" apoquel or temeril p? Or could you say a little something about the risks/benefits associated with each choice?

Misskiwi67 wrote:I want to make it known that while cyclosporine is known to increase cancer risk, prednisone is a potent anti-cancer drug and is a common adjunct for many chemotherapy protocols.

Thanks for the information regarding the potential increased cancer risk. Considering she had a grade 2 mast cell tumor and lymph node removed just prior to me leaving the country, it is a little concerning.

She was doing pretty well on prednisone and I did read it has some nice anti cancer properties. I've read negative effects about long-term steroid use. Is prednisone OK for long term use?

Atopica helped, but my wife believes the Apoquel works better. Molly has been on a raw diet for a couple months now. Currently on pork because we believe beef and chicken were irritating her allergies. Atopica gave her occasional GI issues...

I assume there is a lot more data on prednisone use. Anyone know if it's safe long term? If so I may look into removing her from Apoquel until there's more data and returning her to the prednisone...

I know prednisone wasn't a long term solution for Thor. Relatively quickly my vet wanted to do a liver test to make sure it was functioning properly which in and of itself was enough for me to work hard to figure his good allergies out. She has also said we will try Apoquel for Chloe...once she gets it!!

Choices of drugs for any given dog is a complicated matter - side effects, required effective dose, need for long-term use, and cost all come into play.

Prednisone has more side effects than just about any other drug. Its also potent, cheap, and can be effective AND safe at low doses. The key to prednisone is to use it at the lowest possible dose and consider other options if it is ineffective at low doses. For a lot of owners, prednisone is the only reasonable option for them.

Atopica has fewer sytemic side effects, but more GI side effects. It has the potential to cause cancer due to reducing immune monitoring of abnormal cells, but this effect appears to be rare. The major downside of this drug is the cost.

Apoquel is touted as the affordable, lower side effect option to compete with both of the above. Its so hard to get right now I have yet to see it, let alone try it, although we've been on the list for the medication for months. Since I have no experience with it, I haven't taken the time to learn much more about it.

None of the above was working - got so bad she was in a soft cone the majority of the time unless we were doing something with her or she was sleeping. Tried 2 temeril p - didn't touch her...at all...

saw the derm. today and got a 1 week trial of Apoquel. She's #30 on the list - if it works for her they're going to see if they can do something for her. We're also going to do a blood allergy test next week to see if her allergies have changed. First test was intradermal - don't know why but derm said she was comfortable doing the second test as a blood test - it's been 6 years since her initial test.

She said if the Apoquel is going to work we should notice almost immediate improvement....